Failure to Ensure Physician Orders and Proper Dating of Oxygen Tubing
Penalty
Summary
A deficiency was identified when a resident with diagnoses including malignant neoplasm of the prostate, chronic obstructive pulmonary disease, anxiety, and hypertension was observed receiving oxygen therapy without a corresponding physician's order in place. The resident was cognitively intact, receiving hospice services, and was noted to be using oxygen during multiple observations. Review of the medical record and interviews with staff confirmed that there were no orders for oxygen administration documented in either the paper or electronic records, despite facility policy requiring physician orders for oxygen except in emergencies. Additionally, the oxygen tubing in use for the resident was not dated as required by facility policy, which mandates that oxygen tubing and cannulas be dated and changed weekly or as needed. Staff interviews verified that the tubing should have been dated and that this requirement was not met. The lack of proper orders and failure to date the oxygen tubing were observed and confirmed by both direct observation and staff interviews.